Surge Management.

A comprehensive disaster plan will account for a sudden unanticipated “surge” of patients, the
effective triage of patients (prioritization for care and trans- port of patients), and distribution of patients to hospitals
(a coordinated, even distribution of patients to several hospitals as opposed to delivering most of the patients to the
closest hospital). Review of previous disaster response efforts reveals that patients are frequently transferred without
adequate triage and that patient distribution to existing healthcare facilities is often grossly unequal and
uncoordinated (Auf der Heide, 1996, 2002, 2006).

Disaster planning must include a community mutual aid plan in the event that the hospital(s), nursing home(s), or
other residential healthcare facilities need to be evacuated. Plans for evacuation of healthcare facilities must be
realistic and achievable, and contain sufficient specific detail about where patients will be relocated and who will be
there to care for them. Evacuation of patients was a major challenge to disas- ter response efforts following
Hurricane Katrina, and it was hampered by the destruction of all major transportation routes in and out of the city
(Burkle, 2009). Twelve people died after a Florida nursing home failed to evacuate its residents, who suffered for
days in oppressive heat with no air-conditioning after Hurricane Irma (Nedelman, 2017). Preplanning for the
possibility of evacuation of entire healthcare facilities must address alternative modes of transportation and include
ade- quate security measures (see Figure 1.4).

Nuclear events, highlighted by the Fukushima and the Chernobyl experiences and the inherent threat posed by North
Korea for nuclear warfare, present serious challenges for disaster planning. Considering that over one-third of the
U.S. population lives within 50 miles of a nuclear reactor (Physicians for Social Responsibility, 2011), determining
appropriate evacuation zones is crucial. The correct evacuation distance from a nuclear event depends on the style of
the nuclear device, type of radiation released, building structures, prevailing wind patterns, river/ ocean currents, and
populations living in the fallout area (Fong, 2007; U.S. Department of Health and Human Services, 2017a, 2017b).
Disaster planners need to evaluate all of these elements when planning and establishing evacuation zones in nuclear
events (see Figures 1.5 and 1.6).

1. Resource identification is an essential feature of disaster plan- ning. A community’s capacity to withstand a
disaster is directly related to the type and scope of resources available, the presence of adequate
communication systems, the structural integrity of its buildings and utilities (e.g., water, electricity), and
the size and sophistication of its healthcare system (Burstein, 2014; Cuny, 1998). Resources include both
human and physical elements, such as organizations with specialized personnel and equipment. Disaster
preparedness includes assembling lists of healthcare facilities; medical, nursing, and emergency responder
groups; public works and other civic departments; and volunteer agencies, along with phone numbers and
key contact personnel for each. Hospitals, clinics, physician offices, mental health facilities, nursing homes,
and home care agencies must all have the capacity to ensure continuity of patient care despite damage to
utilities, communication systems, or their physical plant. Redundant communication systems must be put in
place so that hospitals, health departments, and other agencies, both locally and regionally, can effectively
commu- nicate with each other and share information about patients in the event of a disaster. Within
hospitals, departments should

1 Essentials of Disaster Planning 15

have a readily available, complete record of all personnel, including cellular phone numbers to ensure
access 24 hours a day. Resource availability will vary with factors such as time of day, season, and
reductions in the workforce. Creativity may be needed in identifying and mobilizing human resources to
ensure an adequate workforce. Disaster plans must also include alternative treatment sites in the event of
damage to existing healthcare facilities or in order to expand the surge capacity of the present healthcare
system.

Coordination between agencies is also necessary to avoid chaos if multiple spontaneous volunteers respond
to the disaster and are not directed and adequately supervised. As with the September 11 (9/11) disaster,
many national healthcare workers and emergency medical services responders who came to New York to
help returned home because the numbers of volunteer responders overwhelmed the local response effort.
CORE PREPAREDNESS ACTIVITIES

1. Prepare a theoretical foundation for disaster planning. Disaster plans are “constructed” in much the
same way as one builds a house. Conceptually, they must have a firm foundation grounded in an
understanding of human behavior. Effective disaster plans are based on empirical knowledge of how people
normally behave in disasters (Landesman, 2011; Lasker, 2003). Any disaster plan must focus first on the
local response and best estimates of what people are likely to do as opposed to what planners want people
to do. Realistic predictions of population behaviors accompanied by disaster plans that are flexible in
design and easy to change will be of greater value to all personnel involved in a disaster response.

2. Disaster planning is only as effective as the assumptions upon which it is based. The effectiveness of
planning is enhanced when it is based on information that has been empirically verified by systematic field
disaster research studies (Auf der Heide, 2002, 2006). Sound disaster preparedness includes a
comprehensive review of the existing disaster preparedness literature.

3. Core preparedness activities must go beyond the routine. Most disasters cannot be managed merely by
mobilizing more equipment, personnel, and supplies. Disasters differ from routine daily emergencies, and
they pose significant problems that have no counterpart in routine emergency responses. Many disaster-
related issues and challenges have been identified in the disaster literature, and they can be anticipated and
planned for (Auf der Heide, 2007).

4. Have a community needs assessment. A community needs assessment must be conducted and routinely
updated to identify the preexisting prevalence of disease and to identify those high-risk, high-need patients
who may require transport in the event of an evacuation or whose condition may necessitate the provision
of care in nontraditional sites. This needs assessment provides a foundation for planning along with
baseline data for establishing the extent of the impact of the disaster.

5. Identify leadership and command post. ICS is the mandated leadership form for leading an emergency
response (FEMA, 2015). The issue of “who’s in charge” is critical to all